BERKELEY, CA (UroToday.com) - Acute urinary retention (AUR) is a common condition affecting men and is often associated with benign prostatic hyperplasia. The initial management of these patients presenting with AUR involves immediate bladder decompression, either by urethral or suprapubic catheterization. These patients will usually be given α1-blocker, followed by a trial without catheterization (TWOC) 3-4 days later. However, the question whether these patients should be admitted to the hospital remains unanswered. There is no consensus on the hospital admission criteria for patients presenting with AUR, and the hospitalization rate for AUR varied significantly among different countries.
Many of the patients presenting with AUR run a relatively stable course after catheterization. Hospital admission of these patients, for observation alone, may not be necessary, and may expose them to the risk of hospital-acquired infection. Ideally, patients presenting with AUR who are expected to run a stable course after catheterization should be managed on an outpatient basis. It does not only reduce the risk of hospital-acquired infection, it may also relieve the workload of the medical staff and reduce the economic burden of the hospital. On the other hand, managing these patients on an outpatient basis may be difficult practically. Firstly, it may be difficult for physicians at the emergency department to identify low-risk patients who can be discharged with a urethral catheter. Secondly, referral to the urology team after being discharged from the emergency department takes time, and this may lead to inappropriate prolongation of catheterization, hence increasing the risk of catheter-related complications such as urinary tract infection.
The solution to this problem is to implement an ambulatory care program between the urology team and the emergency department for patients presenting with AUR. The aim of the program is to standardize the care in managing AUR while avoiding unnecessary hospitalization. Admission criteria should be clearly set to facilitate identification of patients who require hospital admission after catheterization. For those patients who can be discharged with urethral catheter, α1-blocker should be prescribed till the day of TWOC. Urologists should assess these patients on the day of TWOC to ensure proper urological assessment and discussion on the future plan of management.
In our prospective cohort study, we aimed to investigate the role of our ambulatory care program in managing patients suffering from AUR. The TWOC success rates, before and after the implementation of the ambulatory care program, were comparable. For patients who were managed on an outpatient basis, only 4 out of 194 patients (2.1%) had unplanned admissions, all of which were managed accordingly, without resulting in any unfavorable sequelae. The results of our study confirmed the safety of the ambulatory care program in managing AUR without jeopardizing the TWOC success rate. In addition, the ambulatory care program reduced the hospital admission rate of male patients presenting with AUR by 59.1%. This, in turn, resulted in a significant cost reduction of approximately USD 375 614 in our hospital in year 2008. Although a cost-effective analysis is needed to formally evaluate the cost-effectiveness of this ambulatory care program, the economically favorable outcome that our study demonstrated is already very encouraging.
Although the implementation of the ambulatory care program involves intensive collaboration and cooperation between the urology team and the emergency department, we believe that this not only maintains the standard of care in managing AUR, but it also brings significant positive economic impact to the hospital, and ultimately benefits our patients.
Written by:
Anthony C.F. Ng, MBChB, MD (CUHK), FRCS (Edin), FHKCS, FRCS Ed (Surg), FHAM (Surg) as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Professor, Division of Urology, Department of Surgery
Course Director, Robotic Surgical System Training Programme
CUHK Hong Kong Jockey Club Minimally Invasive Surgical Skill Centre
The Chinese University of Hong Kong
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